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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247201317
Report Date: 02/10/2023
Date Signed: 02/10/2023 01:02:27 PM


Document Has Been Signed on 02/10/2023 01:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GUARDIAN ANGEL HOME CAREFACILITY NUMBER:
247201317
ADMINISTRATOR:SILVEIRA, LIDIA FATIMAFACILITY TYPE:
740
ADDRESS:4345 VAUGHN AVENUETELEPHONE:
(209) 388-9447
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY:5CENSUS: 0DATE:
02/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lidia SilveiraTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct the case management - health and safety inspection for facility closure. LPA met with Administrator Lidia Silveria.

LPA and AD toured the facility. All residents have been relocated. AD provided the locations of the former residents to LPA.

AD surrendered the facility license to LPA.
Forfeiture of License letter was given to AD during the visit.











An exit interview was conducted and a copy of this report as well as was left with Lidia Silveira, whose signature confirms receipt of these documents.
.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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